Short Take

Demystifying Teaching

Training faculty members to improve their teaching skills shouldn't
be a revolutionary idea. But it is.

By Sara Selis
Photographs Trujillo/Paumier

In the late 1970s, a Stanford internist named Kelley Skeff saw a void
in academic medicine: neglect of the craft of teaching. Teaching was
a significant part of all medical faculty members' work but in most cases
no one bothered teaching them how to teach. Having worked with dozens
of clinical teachers during a general medicine fellowship at Stanford,
Skeff observed that many physicians in academic medicine struggled with
teaching and did so alone.

So Skeff had an idea: Why not design a program to teach medical faculty
how to be better teachers, using a systematic, logical approach?

For some in academic medicine, this was an unusual  even radical  idea.
Many viewed teaching as a natural gift: either you had it or you didn't.
Others simply assumed that MDs, being intelligent people, knew how to
teach.

But Skeff felt that excellence in teaching was too important to be left
to chance.

Appreciation of Skeff's idea has grown among medical school faculty
and administrators nationwide. In the late 1970s, there were just three
or four faculty development programs targeting medical faculty. Today
there are more than a dozen. And the Stanford program Skeff developed
is thriving and expanding its role in training Stanford faculty and their
counterparts throughout the world.

Not such a crazy idea after all

Even back in the 1970s, several people found Skeff's idea reasonable.
Among them were two of his Stanford mentors, Daniel Federman, MD, and
Harold Sox Jr., MD, who encouraged him to pursue his interests through
a PhD in education. In 1978 Skeff followed their advice, enrolling in
Stanford's School of Education. Working toward his thesis with professor
Nathan Gage, Skeff videotaped hundreds of hours of teaching by Stanford
medical faculty. He also noted which teaching behaviors students rated
highly and which ones students found less effective. Skeff meanwhile
met Georgette Stratos, a UC-Berkeley doctoral student in educational
psychology who was doing a project on doctor-patient communication at
the Palo Alto Veterans Affairs Hospital.

The two began collaborating on Skeff's project, and their efforts evolved
into a comprehensive framework that faculty could use to analyze their
teaching. The framework highlights seven facets of the student-teacher
interaction  including "learning climate," "communication of goals" and "understanding
and retention"  and provides a teaching strategies checklist for
each. For instance, the checklist for "feedback" includes these strategies:
Tell learners whether their performance is correct, explain why their
performance is or isn't correct, and let learners react to feedback.

While these concepts weren't new, Skeff and Stratos brought them together
and applied them to medical education  something no one had done
before. "We wanted to give teachers a comprehensive, systematic way of
examining all aspects of their teaching," Skeff explains.

The framework became the centerpiece of Skeff's thesis, in which he
worked with dozens of Stanford medical faculty one-on-one to improve
their teaching. In the early 1980s, Skeff and Stratos tested the method
with small groups of faculty members in a program called the Clinical
Teaching Seminars. In 1985, they secured a grant from the U.S. Department
of Health and Human Services, which enabled them to set up shop, and
in July 1985 the Stanford Faculty Development Center for Medical Teachers
was born.

Today, Skeff is hailed as a pioneer in medical education, and the clinical
teaching program he and Stratos created (and still co-teach) is considered
the gold standard for faculty development in medical education. The program
is cited in the medical education literature, is presented at national
society meetings and has been adopted by dozens of medical schools. It
has also secured grants from the Macy, Hartford and Robert Wood Johnson
foundations.

Furthermore, research showing that graduates of the program are subsequently
more versatile in their teaching and receive higher student ratings confirms
the effectiveness of Skeff's approach.

The Stanford Faculty Development Center is "the pre-eminent faculty
development program in the country," says Wendy Levinson, MD, vice chair
of the Department of Medicine at the University of Toronto and past-president
of the Society of General Internal Medicine.

Nowadays, Skeff and Stratos continue to co-direct the program, offering
the Clinical Teaching Course to small groups of faculty, who come from
around the world to attend the intensive monthlong session. The center
also offers courses that teach faculty to teach specific subject matter
based on the principles in the clinical teaching program. Current courses  taught
in collaboration with other Stanford faculty  focus on geriatrics,
end-of-life care and contemporary medical practice. More than 225 faculty
members at 112 medical schools, including several at Stanford, have completed
courses at the center, and all of them have presented the material to
faculty and residents at their home institutions  a "train-the-trainer" model
that has enabled Skeff's ideas to have an exponential impact on medical
education.

Skeff is gratified by the attention the program has received. But what
he finds most rewarding is the way the program transforms the careers,
and lives, of those who complete it.

"The utility of this work becomes clear every time we work with a new
group," explains Skeff, who also directs Stanford's internal medicine
residency program. "When you help a teacher discover a powerful new idea
about teaching, and you see their potential for teaching others  that
gets you pumped up."

A life-altering interlude

Consider Robert Centor, MD, who describes his month at the Stanford
Faculty Development Center as "a breakthrough" that "helped me understand
who I wanted to be and how I would get there." Now director of the division
of general internal medicine at the University of Alabama School of Medicine,
Centor completed the since-discontinued preventive care course in 1991.

Centor says the framework opened his eyes. "Before, I could say 'So-and-so's
a good teacher' but I couldn't say why. The program provides a tool that
allows you to critically examine your teaching, to identify your strengths
and weaknesses."

Centor had always been knowledgeable and passionate about what he taught.
But when he reviewed his videotaped teaching sessions and analyzed them
according to the framework  an exercise early in the course  he
realized some aspects of his teaching were ineffective: He rarely asked
questions to gauge students' comprehension of the material; he avoided
discussing subjects he didn't know about; he responded bluntly to students'
incorrect answers; and he generally remained aloof from students.

"If I didn't agree with what a student said, I'd say, 'That's wrong,' "Centor
says. "Ultimately, I realized I was intimidating my students." The course
taught Centor more effective teaching behaviors, such as using personal
examples to explain material, and giving positive feedback along with
negative.

Centor then practiced these strategies in the role playing sessions
that are a core element of the program. Course participants take turns
playing the roles of students (for instance, a distracted intern, a timid
medical student, or an opinionated resident who's been up all night)
and of the teacher (the attending physician).

After playing their roles for three minutes, the group reviews the scene
on videotape, discusses how effectively the attending physician dealt
with the challenges presented and brainstorms alternate strategies. The
group repeats the role play, with the teacher trying out the suggested
behaviors.

The exercise can be painful, Centor admits. "The first time you see
yourself on videotape, you cringe. You say 'My god, do I really do that?'
But once you get used to the idea that you weren't as good as you thought,
you can accept that and move forward."

Stratos  who oversees the Faculty Development Center's day-to-day
operations  says the program can be "a very transformational experience.
People are making themselves vulnerable. They're looking at themselves
in a way they haven't before, and that helps them make changes."

Today, Centor's teaching style is much different  largely due
to the Stanford course. He routinely gives and seeks feedback. If he
doesn't know the answer to a question, he admits it  something "I
was too cocky to do before."

Since completing the Stanford course, Centor has won several teaching
awards and says he enjoys teaching more. And the medical school's residents
rank his division as the best at teaching  something Centor attributes
partly to the fact that most of its faculty have been exposed to the
Stanford course, directly or indirectly.

The course continues to elicit praise from its graduates, years after
they've participated. "It was a turning point in my personal and career
development," says Louis Pangaro, MD, a 1987 graduate of the clinical
teaching course, now vice chairman for educational programs in the Department
of Medicine at the Uniformed Services University's medical school. Pangaro
offers the faculty development course to all of the school's residency
program directors.

Teaching at the bedside: Professor
Ted Harris, MD, the attending physician for these Stanford rounds
(second from left), is a teaching program graduate.

Going local

Ironically, the Stanford Faculty Development Center, situated in the
Stanford Barn, is relatively little known at Stanford. But this low profile
on campus should change soon: Stanford is the test site for offering
the course to basic science faculty. Since August 2001, 27 Stanford basic
science teachers have completed the 15-hour teaching seminar.

"The course is terrific. It changes the way you think as a teacher," says
Eric Knudsen, PhD, chairman of Stanford's neurobiology department, who
attended the seminar in August. "I think all our faculty should take
it as a prerequisite for joining the faculty."

Another irony: Even as more attention is paid to faculty development
in medical education, academic medicine faces mounting pressures  regulatory,
financial and time pressures  that make it difficult for faculty
to devote themselves to good teaching. "There are lots of academics who
care intensely about teaching, but they can't teach as much or as well
as they'd like," Skeff laments.

The upshot is that all this seems to make Skeff's efforts that much
more relevant. "All the pressures make it even more important that this
kind of program continue," Levinson says. "There's still so much work
to do."